The pain syndrome in chronic pancreatitis is a difficult and not well understood phenomena. When the disease is so heterogonous to start with, one can not expect that one treatment modality alone can take the role of becoming the standard treatment of choice. Rather the goal should be to offer a set of choices, so as to suit the treatment to the specific case and to the solitary patient.
Chronic pancreatitis is a disease that the patient must expect to live with for many years, and this especially applies to patients in whom the disease debuts at an early age. Hence, if the patient experiences pain that makes opioid treatment prevalent, the surgeon should have a role in adjusting the treatment. In addition, toxic etiology, i.e. alcoholic pancreatitis, aught to make the doctor aware of the greater risk of pancreatitis associated complications, which inevitably makes the patient a surgical candidate.
ERCP is a good start, but has yet to show convincing long-term effects in any prospective trials. It still does provide symptom relief for many and should always be considered. It is here important though to know that endotherapy should not be offered as a first line of treatment for the simple reason of being the least harmful of the different invasive modalities, but only when the patient fulfils certain criteria’s. These should, in my view, be: signs of obstructive type of chronic pancreatitis; when there is a presence of strictures, these should be positioned distally; preferably there should not exist multiple strictures (“chain of lakes”); there should not be any radiological findings suggesting the presence of an inflammatory mass in the pancreas; no pseudocysts without ductal communication; and no signs of malignancy. Technically successful dilation of strictures does not necessarily correlate with symptom relief, and one should not hesitate to offer surgery if and when a patient, that has gone through a successful endotherapy, experiences persisting or relapse of symptoms. With regards to pancreatic stones, it is possible to achieve good results with lithotripsy (ESWL), and one might also include endoscopic extraction of stone fragments. Though the stones ought to be positioned distally and not be larger than 10 mm. Current knowledge suggests that, although ERCP is the treatment of choice in acute attacks of pancreatitis, the pain syndrome seen with chronic pancreatitis is to complex for it to be adequately addressed by endotherapy alone.
Recent research indicates that surgery provides more successful results, and that surgeons should take the role of cleaning up what is left behind from the gastroenterologists. Aiming the operation at the pancreatic head has proven to be important, but nothing suggests that more extensive surgery provides better results. The more organ sparing techniques have all shown exceptionally good results, where the majority of the patients, after years of follow-up in the latest randomized trials, have proven to be either symptom free or to have experienced substantial pain relief. The choice between pylorus sparing and duodenum sparing pancreatectomy, or the extended drainage techniques should lie in the hands of the surgeon performing the procedure, and the decision should be based on what the surgeon is most comfortable with. No studies suggest that either one of them provides better long-term results than the others. What is important though is flexibility, and that whoever performs the operation is willing to convert peroperatively to i.e. also include a longitudinal pancreaticojejunostomy when faced with extensive changes throughout the gland, to avoid manipulation of the portal vein system when observing portal vein occlusion with extensive shunting and formation of fundic and duodenal vareses, to include the common bile duct into the anastomosis between the gland and the jejunum when suspecting possible postoperative complication with cholangitis, or to include the duodenum in the resection when there is affection of it.
With regards to the small subgroup of patients that present with a clinic compatible with chronic pancreatitis, but where there are few radiologic findings correlating to the clinical picture, one should be reluctant to perform extensive resective surgery, as is what some institutions seem to recommend. Denervation surgery can be an appropriate offer in these circumstances, but the position of this treatment modality is weakened by the fact that it still does not have any randomized trials to support it with. A possible explanation for the pain that these patients experience is extensive fibrosing of the gland and reduced elasticity, thus one should also consider some of the drainage procedures, such as the Partington-Rochelle or the V-shaped excision.